When parents split up and live in an atmosphere of high conflict, both they and their children often suffer dire emotional consequences (Gurman, Lebow, & Snyder, 2015; Snyder, Castellani, & Whisman, 2006). Effects of marital conflict on children’s adjustment are well documented (Cummings & Davies, 2002). Smyth and Moloney (2019) claim that high conflict cases are among some of the most complex challenges for professionals to deal with. In contrast to amicable break-ups, families almost perpetuate the conflict and the conflict appears to find no end (Sheehan, 2018). Several studies point to the necessity of differentiating between various degrees and types of conflict to better understand these cases and provide the most appropriate interventions (Birnbaum & Bala, 2010; Helland & Borren, 2015; Helland et al., 2020; Johnston, 1994).

The meaning of ‘conflict’ is argued to be vague and not sufficiently defined as a basis for determining between constructive and destructive conflict. Differentiating between constructive and destructive conflict styles among parents is paramount when it comes to predicting positive versus negative outcomes for the children involved (Cummings, Goeke-Morey, & Papp, 2016; Davies & Cummings, 1998; Reynolds, Houlston, Coleman, & Harold, 2014). Sheehan (2018) makes a distinction between two facets of a post-separation conflict, namely the grounds on which a conflict takes place and the relational processes through which the conflict has been brought into being and maintained.

Different process models and frameworks have been developed to address the continuum of influencing factors of interparental conflict and discord and how they serve as a significant influence on children’s development (Cummings & Davies, 2002; Cummings, Goeke-Morey, & Papp, 2016; Polak & Saini, 2015). Research on parental functioning and the aetiology of child maltreatment is often focused on and has been identified as containing three domains: (1) resources of parents, (2) characteristics of children, and (3) contextual sources of risk and protecting factors. Knowledge of patterns of post-divorce relationships and their different trajectories, the evolution of high conflict, and protective factors in children’s adjustment to enduring parental conflict, emphasise the necessity of a broad approach when professionals encounter children and parents. Consequently, the ability to distinguish poor and dysfunctional parenting from child emotional maltreatment is known to be challenging (Sudland & Neumann, 2020; Wolfe & McIsaac, 2011).

If we are to understand the conflict’s trajectories and take into account the risk they represent, we need to look more closely at the nature of a conflict (Drapeau et al., 2009). With a firm emphasis on conflict and its possible resolution, there is the potential among professionals to miss the need for the development of certain skills in order to understand the conflict. The emphasis is instead on the conflict’s continuum instead of understanding the contextual background and building a structure of potential containment around the conflict (Sheehan, 2018). Consequently, if professionals are expected to understand the conflict, they need to understand the context in which the conflict takes place and the patterns that perpetuate it (Lorås, 2021). This is in line with a systemic understanding, which claims that humans’ challenges (individuals, couples, and families) need to be put in a contextual frame, where the nature of the relationships involved is assessed (Capra & Luisi, 2016). Thus, each individual’s description of the interactional problem makes little or no sense without the relationships of those involved being assessed and taken into account. Different persons will understand and explain the conflict differently, for example, offering competing descriptions. It is therefore not appropriate to consider high conflict as an objective ‘truth’ where people are expected to have a common understanding.

The research literature (Anderson et al., 2010; Haddad, Phillips, & Bone, 2016; Johnston, 1994; Kosher & Katz, 2022; Smyth & Moloney, 2019; Stokkebekk, Iversen, Hollekim, & Ness, 2021) shows great variation in terminology when describing parental conflict. Coleman (2014) labels prolonged marital disputes as intractable conflicts characterised by escalation, hostile interactions, sentiment, and a change in quality over time. Typically, associations are cycles of high and low intensity, destructiveness, often costly in human and economic terms, that can become pervasive and affect day-to-day aspects of the disputants’ lives (Coleman, Vallacher, Nowak, & Bui-Wrzosinska, 2007). In this article, we use the term ‘high conflict’ as a collective designation of parental conflicts that are enduring and of such intensity that they constitute a major risk factor to children’s adjustment.

Theoretical perspective: Tame and wicked problems

No phenomenon (such as high conflict) can be explored and examined without some set of guiding theories, contextual factors, and perspectives. These elements are like a set of assumptions or lenses through which we look at what we are interested in (Sheehan, 2018). A variety of different theoretical perspectives can be used to shed light on high conflict. Examples are family systems theory (Priest, 2021), attachment theory/attachment narratives (Bowlby, 1973), emotion theory (Ben-Ze’ev, 2000), conflict theory (Coleman, Deutsch, & Marcus, 2014), and trauma theory (Akhtar, 2017).

In understanding high conflict, we have chosen Rittel and Webber’s (1973) tame and wicked problem analysis. Consequently, tame and wicked problems will be used as a theoretical frame of reference to explore our data. Wicked problems are characterised as problems that lack clarity in their aims and solutions and are therefore difficult to solve due to their complex and interconnected nature. In contrast to tame problems, wicked problems cannot be handled as a system of enumeration phases in order to understand the problem or the mission, gather information, analyse information, synthesise information, and finally develop a solution. Due to the dynamic social context within which wicked problems arise, the type-of-schemes approach does not work as one cannot understand a problem without knowing about its context. One cannot first understand and then solve the problem as there are no solutions in the sense of definitive and objective answers (Rittel & Webber, 1973). Possible solutions depend on how the problem is framed.

The setting up and constraining of solution space and measures of performance are the wicked part of a problem. Wicked problems are characterised by the involvement of multiple stakeholders who may have radically different worldviews and different frames for understanding the problem. The constraints that the problem is subject to, and the resources needed to solve it, might change over time and/or the problem may never be solved definitively. Wicked problems occur in any domain involving stakeholders with differing perspectives. Normal solutions no longer seem to work; there might be no agreement on the nature of the problem, and certainly no clear view on what interventions might work to resolve it. There are complex interdependencies which may reveal or create new problems when trying to solve aspects of the wicked problem (Rittel & Webber, 1973).

This study was conducted in Norway, where child and family public services are organised within the overall welfare state. Norway is a nation with a strong element of control and where public services have authority to make intrusive interventions into family life (Helland, Pedersen, & Skivenes, 2022). Like Australia, Norway is one of the few countries to have mandatory mediation when parents split up, framed within the Children Act (1981) article 51. The child welfare system has a broader scope than other more liberal Western countries’ child protection systems (for further descriptions, see Heggdalsvik & Samsonsen, 2022; Samsonsen, 2016). Based on the experience and understanding of high conflict by professionals in family counsellor services (FCS) and child welfare services (CWS), the research question of this paper is: How do professionals in family counsellor and child welfare services understand and experience high conflict in terms of complexity?

Methods

A qualitative approach was selected to assimilate professionals’ understanding and experiences of high conflict in Norwegian FCS and CWS. Consequently, a qualitative approach based on reflexive thematic analysis was chosen (TA) (Braun & Clarke, 2006, 2019; Clarke & Braun, 2018).

Recruitment

The recruitment aimed to obtain a strategic and heterogeneous range, which is a characteristic of qualitative studies (Thagaard, 2013). A strategic range means that the participants were chosen based on the characteristics or qualifications that were strategic relative to the research questions and the study’s theoretical perspectives (Thagaard, 2013).

Twenty-two women and two men were interviewed. The participants’ experience of FCS and CWS varied. To safeguard their anonymity, we have used pseudonyms in the presentation of the findings.

Focus group interviews

Findings presented in this paper are based on empirical data from four focus group interviews conducted in January 2020. There were two focus group interviews with participants from FCS and two focus group interviews with participants from CWS, with a total of 24 participants. A request with information about the study was sent to managers of the different services. To ensure that we shed light on the research question, the services were asked to provide informants whose day-to-day work involves parental conflict.

The interviews were conducted by the first and third authors at the different services’ offices. All interviews lasted approximately 90 minutes and included a small break. The interviews were recorded and transcribed by an external party immediately after the interviews were conducted.

The informants were introduced to eight question cards¹ organised into two main topics. One of the informants in each group was responsible for asking questions from the cards in chronological order. The participants were instructed not to look at the next card before the focus group had agreed that they had fully discussed each question. The main topics contained the two headings: (1) What inhibits and what promotes constructive co-operation between the CWS and the FCS in cases concerning deadlocked parental conflict? and (2) What is collaboration practice like between the FCS and the CWS in situations where the services are concerned about the children’s care situation?

The participants were presented with the following questions: (1) What distinguishes your meetings with children and families in these situations? (2) Children living in families with deadlocked parental conflict might involve two acts: The Children Act, and the Child Welfare Act. What do you think about that? Eventual experiences. (3) Which experiences do you have with regard to reporting concerns about children? What circumstances trigger your duty to report the way you see it? Can you please discuss what assessments precede a report of concern? Can you please express what assessments you make in advance of such enquiries? (4) Do you have any thoughts or suggestions on what the FCS and the CWS can do in order to help children living with deadlocked parental conflict that gives rise to concern?

Data Analysis

The analysis is based on the transcriptions of what the professionals at the FCS and CWS discussed in relation to the questions presented. The emphasis was on the content of the professional family counsellors’ and child welfare case workers’ assessments and reflections. Inspired by TA, statements were read thoroughly several times and analysed (Braun & Clarke, 2006, 2019; Clarke & Braun, 2018). To increase the credibility of the data and to capture themes, the first author of this paper worked separately with the data before coming together with the third author several times for co-reading and discussions. A key consideration when selecting a theme was its significance capt in relation to the overall research question (Braun & Clarke, 2006).

TA is not bound to a specific theoretical or epistemological approach and consequently offers considerably flexibility. We used four steps, inspired by TA (Braun & Clarke, 2019): (1) Familiarisation with the data: the first author read and re-read the dataset several times writing down the initial ideas about possible themes. (2) Based on the tentative ideas and themes from step one, the second phase involved systematically coding interesting characteristics in the data material. (3) Step three involved identifying and naming themes among the numerous codes in the data material, which were: (a) unclear definition of high conflict, (b) conflicting agendas causing stress in the family system, (c) being a professional working with high conflict, (d) calls for further knowledge and resources, and a transdisciplinary approach. (4) The fourth step involved the preparation of the written ‘report,’ in this case the article. The first author was responsible for the first draft of the various sections and sent them to the other two authors for their comments and feedback.

Research ethics

All procedures were conducted in accordance with the Helsinki declaration of 1975, as revised in 2000 (World Medical Association, 2013). This study was approved in 2019 by the Norwegian centre for research data (# 981003). All participants signed a consent form and received copies of the approvals for the research project. All informants were informed about their right to withdraw from the research project at any stage without the need for explanation. All transcripts were anonymised.

Findings

Each finding is exemplified by quotes from the participants. Using focus group interviews, our questions generated discussions between the participants. However, the interviews were not characterised by disagreements, rather reflections mirroring the headings of the different themes. Thus, we have decided to show only short extracts from the transcriptions.

Unclear definition of high conflict

The informants emphasised the challenge of breaking down and concretising the phenomenon of high conflict. They were, in general, clear that the term ‘high conflict’ is multifaceted: ‘These are the cases we find most difficult to work with’ (FCS1). They stated that the terms used to describe the phenomenon is the professional services’ term and were not sure whether the parents understood the term or how professionals saw and categorised them as parents. The informants also noted great variation in how conflicts turn out in different families, but complexity was a key term. There are differences in stories and often a long history with other problems ‘behind’ parental conflicts. Often discussions among parents end up being very detailed, which makes it challenging as a professional to interpret what the situations are about. The latter noted the ease of getting trapped in the conflict and becoming an intermediary and, as a result, there is a real danger of not being able to do anything.

The informants also problematised another aspect of working with high conflict, in that there is a possibility that the label ‘high conflict’ in itself is challenging: ‘High conflict becomes the definition of the problem; it stops us in a way, and we do not know how to handle it’ (FCS4). By labelling a situation as high conflict, there is a greater risk of losing sight of the children involved and a greater chance of categorising the situation as a ‘high conflict case’ and not a ‘child neglect case.’ The informants also discussed the risk that services can become paralysed by the conflict, which may result in children not getting help because no one dares to be involved with the family due to the high conflict label.

Conflicting agendas cause stress in the family system

In all four groups, there was consensus that children experiencing enduring parental high conflict are at risk. The conflicts cause severe stress and are described as stressful for everyone involved. During conflicts, the professionals described children as confused and always on edge and easily losing focus in their day-to-day lives. One informant used the term ‘extremely skilled balancing artists’ (FCS4) when describing the children. Several dilemmas were pointed to as examples of the harm that high conflict inflicts on children. Children were observed to be in the middle of the parents’ conflict and the professionals were concerned about the children’s feelings and their expressions of a need to be loyal to both parents. Another dilemma is the experience of a high degree of neglect in many high conflict families because children feel they are not seen. Sometimes children need to be taken into care because there is no other solution. This dilemma was reflected on in terms of whether it is fair for professionals to consider taking children into care due to insufficient measures. Another dilemma is valuable time in a child’s life versus the time professionals spend in their attempts to help: ‘So we actually think that these children have to endure quite a lot while we as professionals try to find measures that will work out, and that is a dilemma, yes’ (CWS2).

There was consensus in all four focus groups that professionals experience parents as vulnerable, and that parents easily misunderstand. Often, as a result, parents claim that the professionals are choosing to side with one of the parents in the conflict. The parents are described as mostly claiming their own needs and seeing themselves as the violated party in the conflict. One of the informants put it this way: ‘It is madness that they do not see how much the conflict damages and destroys.’ As part of their discussion, they reflected on the question of what they as professionals can do to make parents understand how harmful these conflicts are towards their children. On the other side, one informant raised another aspect in that most parents in high conflicts are in a crisis and are negotiating about what is most vulnerable and precious in their life. This negotiation is with the person for whom they hold most contempt, which most likely is not a good starting point for being a reflexive parent.

In addition to children and parents, the professionals also had experience of working with clients’ extended families and networks. These experiences helped professionals to see the conflicts from a broader perspective: ‘It is as if the conflict in itself has a function in the family’ (CWS3). Other informants emphasised the experience of strong familiar forces outside the parents. Grandparents on both sides were often engaged. In some families, it is like family trees who are in conflict with each other, often with several ‘broken branches.’ As part of their work, the professionals sometimes experience progress at one stage, but in the next meeting the situation has changed, and the professionals express a feeling of regress. They often get strong feelings that there are other forces around the parents that are not physically present in the room but are of great influence behind the scenes.

Being a professional working with high conflict

The professionals expressed a mix of feelings when they described their experiences of being a professional working with parental high conflict. There were feelings of powerlessness, discouragement, paralysis of action, exhaustion, and problems that never end but become new ones at different stages of children’s lives. The professionals emphasised the experience of easily being dragged into the ‘high voltage line’ (CWS2). Experiences of sudden realisations that they themselves were caught in the middle of the conflict resulted in reflections that their contribution may even be making the conflict worse. These kinds of situations were expressed as most challenging.

The professionals highlighted time as a dimension. Working with these conflicts takes time and there are several elements to assess and take into consideration. It is easy to get confused and there is a need to regularly reflect on what is going on. The informants were aware of the potential of being dragged into the conflict and becoming part of it, which challenges their endeavours to work systematically. Reflections on their own feelings of exhaustion are transferred to reflections on how these conflicts must be experienced by the children involved. The informants discussed the fact that there are some conflicts that never come to an end. Then they remind themselves of the following: ‘So, when we are eaten up by the parents’ conflict, we must not forget the children’ (CWS2).

The informants emphasised several relevant reflexive questions when assessing the conflicts. First, they raised the overall question of how best to assess these cases. Another challenge is how to decide what level the conflicts are at, what options they have for helping the different families, and how to work with the family in the best way. A key question was also what is most important in a high conflict case and how to decrease the conflict as the starting point for their efforts. The informants discussed what ‘help’ actually is, when working with these families. They also reflected on how they can measure possible improvements in a family. Another issue discussed by the informants was how high conflict situations, often described by the participants as ‘heavy material,’ are allowed by the professional system to last too long. They reflected on experiences of cases that pervade their systems over a long period of time. Several times, they experienced cases that return. A question was raised whether it is ever possible to express that one has succeeded. One of the informants asked: ‘Do we spend too much time on finding the truth?’ (CWS3). Regardless of all questions that were raised during the interviews, they agreed they spend a lot of time trying to understand the core of different conflicts and that they rarely find quick solutions.

Calls for more knowledge and resources, and a transdisciplinary approach

An overall description from one of the focus groups was the importance of structure and methods. The informants also asked for more research on already established structures and methods. Due to the experience of the challenge in helping children and parents when parents have reached the point of an intertwined high conflict, the informants discussed several areas of improvement for how they do their work. Emphasis was placed on prevention factors at different levels. Informants from CWS expressed a lack of appropriate services for support. They all pointed towards a need for increased knowledge about fracture processes among parents in general in society. The informants also pointed to the need for professionals to gain more knowledge about deadlocked parental high conflict and how to work within these families, as well as to develop a more common understanding among professionals.

The informants all agreed on the importance and need for transdisciplinary collaboration in general around families involving high conflict between parents. Nevertheless, experiences and reflections expressed: ‘That is what is so difficult, what can we do, how can we possibly achieve something, how can we achieve constructive collaboration, what do we actually want with collaboration, what do we actually wish to achieve?’ (FCS4). The informants pointed towards unclear expectations of each other’s services, expressing unclear boundaries between services and differences in mandates and jurisdictions with a struggle to find the right point for overlap while not quite knowing what other services are doing and how to collaborate. On the other hand, the informants emphasised the value of collaboration, so they do not lose sight of the children.

Another aspect mentioned was that families access collaborative services to get the most appropriate help, but the dilemma is that children are unable to receive it. Parents involved in high conflict harmful to their children may refuse any help from the counselling service since it is voluntary. Services may have an earlier experience of parents concluding they may not benefit from help because of not seeing changes in behaviour. Another aspect was the parents who refuse more help in cases where CWS ought to act and argue in court that a child needs to be taken into care due to high conflict. A question raised was what children involved in high conflict are left with if FCS and CWS are unable to help.

Discussion

This study sought to provide insight into how professionals in FCS and CWS understand and experience high conflicts in terms of their complexity. Tame and wicked problems are used as a theoretical frame of reference. While FCS and CWS are given different mandates and are regulated by different laws, their professional understanding and assessments are crucial for children. In line with previous studies, this study also shows that professionals assess high conflict as challenging (Black et al., 2016; Jevne & Andenaes, 2017; Saini, Black, Godbout, & Deljavan, 2019; Sudland & Neumann, 2020). The professionals also seem to be easily ‘trapped’ within the parents’ conflict-based system. As part of attempts not to become part of the parents’ conflict and take sides, professionals face the challenge of how to develop new solutions. The professionals described how feelings of powerlessness, discouragement, paralysis of action, and exhaustion can manifest after struggling with trying to solve the problem. Issues include: (1) professionals find the constant narratives told to support the parents’ own understanding of the conflict challenging; (2) when faced with the relational process, professionals often find addressing the conflict as complex; (3) the stories told are often different, and the starting point for understanding the conflict challenges professionals’ solutions in high conflict cases.

The theoretical descriptions of wicked problems might be helpful when discussing how to approach high conflict cases involving children. This is because the hallmark of wicked problems is not only differences in the definition of the problem, but also different perspectives on how to approach solutions to problems (Rittel & Webber, 1973). When a complex and wicked problem is addressed, a variety of interpretations and responses may be identified, and although each version of the problem has an element of truth, no single version captures the whole problem (Harris, Brown, & Russell, 2010). There are rather different understandings of the ‘truth.’ Targeting one part of the problem can raise problems in another part of the problem, because of the parents’ internal conflicting goals. This can be understood as the problem being circular in nature (Stratton et al., 2009). Based on a circular understanding, changes at one place within the problem system will mutually reinforce the members and parts of the system. Consequently, even a small change will change the entire system (Schjødt, 1989). A systemic understanding resonates in many ways with the problem of framing wicked problems. However, being in intractable conflict, most parents understand it in linear terms and are not interested in or open to an understanding that includes themselves as both a part of the problem and the solution (Lorås & Tyskø, 2019). To them, it is the other party who needs to change.

Our findings show that, in line with Van Lawick and Visser (2015), children are often caught in the middle of two parents with a very different understanding of the conflict. With this divergent starting point, a further challenge is the escalating nature of the conflict (Coleman, Deutsch, & Marcus, 2014). Seeing high conflict through the lens of a risk perspective, which is the responsibility of CWS, the weighing of a child’s adjustment towards their parents as an autonomous system poses a challenge to professionals. A central question is how to approach each family with respect to the parents’ different understanding of the conflict, and at the same time provide support and safety for the children involved (Fluke, Corwin, Hollinshead, & Maher, 2016). Even if their child is at risk, parents in high conflict do not seem to benefit from therapy or similar services offered by professionals but instead seem to resist change even if the conflict is harmful for everyone involved. Family system theory (Priest, 2021) may be helpful in understanding how high conflicts affect the main system they take place within. In high conflict cases, the system mainly consists of the broken couple. Family system theory predicts and explains how people within a system (even a broken couple system) interact, and how interactions inside the system are different from those outside of it. The system responds to stress from inside and outside by making changes to its rule-based boundary-making processes (Priest, 2021). Based on such understanding, the couple will hardly be open to proposals for solutions from professionals outside their system, even if they do not manage the conflict themselves.

If a problem is framed as a wicked problem, there will be no quick-fix solutions, since the main problem is how to define its cause (Rittel & Webber, 1973). Our study points towards an unclear definition which is in line with wicked problems. The problems rarely sit conveniently within any one person, discipline, or organisation, making it difficult to place responsibility (Harris, Brown, & Russell, 2010). An unclear definition and understanding of the concept may challenge the way professionals explore high conflict. It also complicates discussions among professionals by taking for granted that all professionals understand the concept in the same way. Unclear interpretations and interpretations within the framework of their own service may turn the concept into a double-edged sword. There is a chance that the label itself indicates a kind of typology as a self-fulfilling prophecy even before the professionals have met each unique child and family.

The participants asked for more research on helpful methods when working with high conflict. However, trying to identify the ‘correct’ theoretical approach does not seem to be helpful for any of those involved. This is also supported by research, as there seem to be minor differences between the different therapeutic approaches. However, most of them seem to have the same effect (Wampold & Imel, 2015). Consequently, it is more important how professionals work with the parents or collaborate with the partners involved. The nature of wicked problems is multicausality. The problem is, therefore, always changing and unpredictable. It is therefore more fruitful to facilitate new understanding and generate options for managing the problem, instead of solving it. There is no single solution. In working with high conflict cases, professionals argue for different approaches to address the problem. In systemic terms, there is always a multiverse of understanding and possibilities for each problem (Maturana & Varela, 1987). On the other hand, the fact that there are children at risk requires action, and professionals are obliged to prevent child maladjustment. There is a need for consecutive assessments in situations where solutions are rarely stable over time.

The complexity, unpredictability, and instability of high conflicts fit with the framework of wicked problems. An important aspect is professionals’ understanding and interpretation of the phenomenon. Devaney and Spratt (2009) argue that child protection issues are wicked problems that are complex and less amenable to being solved, which allows professionals to focus on achieving better outcomes for children. We argue for high conflict cases to be understood and framed in the same manner. When dealing with a wicked problem, the professionals involved need to be aware of its multicausality and interdependencies. In terms of the consequences of high conflict for the children, parents, and families involved, we argue in line with Harris, Brown, and Russell (2010) the need for an open critical enquiry that acknowledges the paradoxes alluded to in this paper. Rather than searching for new knowledge, methods, and solutions, therapists may benefit from interpreting high conflict as a complex and wicked phenomenon.

Concluding Comments

In this article, a qualitative study of professionals’ experiences and understanding of high conflicts was understood and analysed as wicked problems. By using wicked problems as a theoretical lens, our intention has been to bring an analytical tool to help professionals assess high conflict more widely before ‘rushing into families’ and suddenly getting the feeling of being trapped in the conflict. In arguing that high conflict is a kind of problem that has no correct solution, we stress the importance of spending time analysing it before entering a family situation. Given the phenomenon’s complexity this applies regardless of the contextual frameworks of different countries. There is a wholeness between theory and practice, and one of our intentions in this article is to contribute and raise analytical reflections relevant for both professional practitioners as well as researchers. We hope the article will act as a springboard to a broader discussion in understanding and analysing the phenomenon of high conflict, both for professional practitioners and to stimulate further research.

Limitations

In TA, it is rarely practical, or desirable, to evidence every analytic observation by quoting data (Braun & Clarke, 2019). Consequently, the search for patterns and connections in the data might decrease the presence of the unique voices of the informants. This may entail that an individual contextual framework sometimes is not clearly expressed in an overarching discussion. An obvious weakness of this study is the fact that there were 22 women and only two men in the participant group. Although gender is not relevant to the research question, there is a skewed distribution. A more even selection would perhaps show other findings. Nevertheless, there is, in fact, a predominance of women in the services represented in this study. The findings are therefore of relevance. The difference between the assessments made in the focus group interviews, in contrast to the assessments made in practice is, of course, a limitation of this study.